Head Trauma/Spinal Cord Injury Flashcards
(113 cards)
1
Q
history for head injury includes
A
how was the pt. injured - ask family
loss of consciousness?
2
Q
knowing how the head injury occurred allows you to know
A
what to look for - whether you should call someone emergently
3
Q
what is the most important assessment in Head injuries
A
LOC - awake then sleep - not okay
4
Q
what type of pt. get head traumas
A
elderly - falls
young men - risky behaviors (trauma)
children - shaken baby - bike accidents(helmet wearing)
motorcycle accidents
5
Q
what will complicate your head injury assessment
A
alcohol, drugs, low glucose, CO2, O2, anticoagulants
6
Q
one of the 1st things you do w/trauma pt.
A
check blood sugar (low will decrease mental status)
7
Q
anticoagulants and head injuries
A
did they bleed then fall or fall then bleed
8
Q
S/S of basilar skull fracture
A
csf can leak - rhinorrhea and otorrhea
9
Q
2 physical s/s w/basilar skull fractures
A
battle sign (bruising on back of year unilateral) raccoon eyes - bilateral
10
Q
what don’t we do with basilar skull fractures
A
no NG Tube - could end up in brain/spine
11
Q
what type of tubes do trauma pts. get
A
OG (orogastric) tubes - below the skull
12
Q
how do you check CSF coming out of nose for glucose
A
halo test - halo sign - sent to lab - shine flashlight you see halo - see glucose
13
Q
what type of injuries cause DAI - diffuse axonal injury
A
thrown out of car
rollover accident
fall from height
14
Q
patho of DAI
A
white matter is torn - responsible for communication - axons tear, therefore communication problem
15
Q
how do pt. with DAI present
A
present in coma - decreased LOC
16
Q
GCS guidelines for mgmt. of severe brain injury (DAI)
A
GCS 8 or
17
Q
traumatic brain injury with altered LOC presents, what is the first exam we do, and further exams in the ER
A
non contrast head CT - looking for blood
cervical spine x-ray - can have injury to spine as well with force of traumatic brain injury
18
Q
what is a GCS - Glasgow Coma Scale
A
standardized measure of how awake a person is - designed for head traumas
19
Q
the way a pt. is managed with a head injury is based on preventing what
A
secondary injuries - make timely dx to manage
20
Q
Leakage of spinal fluid is a potential neurosurgical complication. How should a
nurse assess for this complication?
A
C. Test all nasal and ear drainage for glucose.
21
Q
how do we prevent secondary injuries in head trauma pt.
A
make sure pt. has adequate oxy - no hypoxia or hypotensive
22
Q
what is the rule of thumb for preventing secondary injury
A
everything is over a 100 - O2 over a 100, systolic BP over a 100
23
Q
rules for body temperature with head injury
A
keep 97 - don’t let them get a fever
24
Q
what is the most life threatening head injury
A
epidural hematoma
25
what type of injuries result in epidural hematomas
injuries to the SIDE of the head (hit with a bat, fall off of something)
26
patho of epidural hematoma
artery (meningeal) tears - acute bleed in head - compression - herniation through foramen magnum - injury to brain stem - death
27
s/s of epidural hematoma
ipsilateral (same side of injury) pupil dilation
rapid chg. in neuro status (awake then unresponsive)
death
28
what can we do to help ICP
craniotomy - window
| hemi-craniotomy - half of the skull
29
state of conscious is defined by
behavioral changes
| pattern of brain activity of EEG
30
a coma is defined as
GCS of 8 or
31
GCS is based on what 3 criteria
eye opening, verbal and motor response
32
IICP and pupils
oculomotor (cranial nerve 3) compression
| causes both pupils to dilate
33
if 1 pupil dilates with IICP what is it a sign of
neurologic emergency
34
is pupil dilation in IICP an early or late sign
late sign - epidural hematoma is the exception
35
if you have a high suspicion your pt. is brain dead what 2 eye tests will you do
```
Doll’s Eyes Reflex (Oculocephalic)
Caloric Stimulation (Oculovestibular)
```
36
what do you do in dolls eyes reflex (oculocephalic)
move head side to side
37
what do you do in oculovestibular (caloric stimulation) eye test
cold water flush in the ears
38
motor function assessment with IICP
normal - pt withdraws from painful stimuli
| abnormal - noxious stimuli - decorticate/decereberate
39
types of posturing
decorticate OR decereberate
| mixed (decorticate/decereberate) - give better score - document in notes
40
headaches r/t IICP will present like this
continuous -
pressure headaches are more common/worse in the am
vascular headaches are more common in the afternoon
41
type of vomiting r/t IICP
projectile vomiting NOT r/t nausea
42
a change in VS is a late sign of IICP, t or f
true
43
ominous sign of IICP
Cushings Triad - Brady, widened pulse pressure (high systolic lower diastolic) low respiration's
44
temp r/t IICP
no control, pressure is effecting hypothalamus - temp can be very high or very low
45
The care of a patient post TBI includes monitoring for signs of brain-stem herniation and occlusion of cerebral blood flow. A nurse should recognize a deterioration in the patient if which VS changes occurred? Select all that apply.
C.Hypo-tension
D.Bradycardia
E.Hypertension
F.Bradypnea
46
Which respiratory change would a nurse see most often in a patient with IICP?
B.Slow, irregular respiration's.
47
ICP of 8 or less on GCS get what
intubated - need airway
| ICP monitor
48
normal ICP range
0-15
49
what is the procedure called for ICP monitoring
ventriculostomy - risk of infection
50
what increases ICP
valsalva maneuver, seizures, fever, position, straining
51
The nurse is caring for a patient with TBI who has IICP. The physician plans to reduce the cerebral edema by reversing dilation of cerebral blood vessels. Which physician prescription would the nurse expect to accomplish this?
A.Hyperventilation per mechanical ventilation (constricts cerebral blood vessels, creating more room in brain)
52
should you use steroids with TBI pt?
no
53
drugs used to trt IICP
mannitol
54
an increased need for this w/IICP pt
glucose (fuel for the brain) - feed the pt.
55
A patient has developed diabetes insipidus after TBI. Which finding would the nurse expect?
A.Polyuria.
56
Which findings should indicate to a nurse that a TBI has resulted in brain death? Select all that apply.
A.No response to the cold caloric test.
C.EEG tracing is flat.
E.No spontaneous respiration's
57
Following a head injury, a patient has no cough or gag reflex. The correct nursing action for feeding this patient is to
D.use a feeding tube
58
The nurse is caring for a patient with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse’s best action?
A.Notify the physician.
59
The nurse is taking the VS of a moribund patient when the patient suddenly grabs the nurse’s hand. The nurse should
C.talk calmly to the patient while continuing to take the VS.
60
Following visitation on the TBI unit, the nurse observes a patient’s wife sitting alone crying. When approached, the wife states, I’m so worried about him.” Your best response is
B.“Tell me what it is that worries you.”
61
Assessing the SCI - first steps
find out what happened
| stabilize
62
what is a SCI
trauma causing compression, ischemia, edema or transection of spinal cord
63
types of spinal cord injuries
permanent, partial
64
severity of spinal cord injury depends on
where the injury occurred
higher injury the more serious SCI - less rehab potential
lower injury more mobility/function
65
an injury above c4 (where diaphragm is) pt.. will have
respiratory compromise - may be perm. or temp.
| watch pt. very carefully
66
an injury above t6 pt. will have
cardiovascular compromise
67
A patient recuperating from a T4 SCI wants to learn to use a wheelchair.To prepare the patient for use of a wheelchair, the nurse should teach her to do
B. push-ups to strengthen her arm muscles.
68
problems post SCI include
airway, ventilation, circ. blood vol., secondary damage to cord (extension of cord damage)
69
planning/goals for SCI pt.
maint. neurologic fxn, immobility (pressure ulcers/contractures/skin breakdown), how are they going to take care of themselves
70
when suctioning a pt. with an SCI be cautious to avoid
pneumonia - sterile procedure*
71
when treating a SCI pt. be careful to avoid
pulmonary edema - too much fluids
72
within the first 48 hrs. of SCI pt. is at risk for
edema - assessment is so important **muscle check**
73
A nurse prepares to suction the trach of a 15 month old child. What steps should the nurse take in completing this procedure? Select all that apply.
A. Select vacuum pressure between 60-100 mm Hg.
D. Wash hands.
E. Hyperventilate the child with 100% oxygen via resuscitation bag.
F. Remove sterile 8- or 10-French suction catheter from package.
74
max suction times for adult and children
5 sec for child/10 sec for adult
75
Your patient with SCI has just been extubated. Which assessment would indicate signs of laryngeal edema?
D. High pitched crowing sounds on inspiration.
76
a spinal cord above t6 will present with this type of problem
cardiovascular (decreased cardiac output/venous return)no vasoconstriction - everything is dilated out - problems with sympathetic nervous system-
77
s/s of t6
bradycardia (
78
what is the first thing we do w/SCI pt.
IV fluids - vasopressor drugs (levophed)
79
any increase in vagal stimulation (turning/suctioning) w/SCI pt. can cause
cardiac arrest
80
prior to suctioning SCI pt. what should we do
hyperventilate
81
what is an SCI pt. at high risk for
DVT due to vasodilation (pooling of blood), immobile
82
what can we do to prevent DVT in SCI pt
compression boots - make sure on all the time
| lovenox
83
Identify the appropriate actions in the prevention of thrombophlebitis in a patient on bed rest. Select all that apply.
B. Encourage exercises that dorsiflex and plantar flex the ankle.
C. Apply sequential compression devices bilaterally.
D. Prevent dehydration.
E. Periodically elevate the feet and lower legs above level of heart.
84
A nurse should evaluate the effects of Coumadin, used in the treatment of DVT, by looking at the results of which laboratory test?
A. Prothrombin time (PT).
85
drug therapy for SCI pt.
solumedrol
| hyperbaric oxygen therapy
86
if SCI pt. is on methylprednisone what are they at risk for
infection - diabetes - stress ulcers (watch for GI bleed in stool/OG tube)
87
GI problems assoc with SCI pt.
gastric distention
paralytic ileus
stress ulcer - increased acid in stomach
88
fluid and nutrition r/t SCI
feed as soon as possible provided they have good bowel sounds - don't have paralytic ileus/distention
89
The doctor has ordered NG feedings for a patient following SCI. Prior to administering a tube feeding, the nurse should
B. check for tube placement by checking the pH of the aspirant.
90
an injury below t12 r/t GI
bowel is areflexic - decreased sphincter tone
91
what is spinal shock
immediate loss of all reflexes following SCI - no tone
92
is spinal shock temporary
yes - few weeks - after return of reflexes begin bowel program (great implications on rehab programs)
93
trt for constipation in SCI pt.
daily suppository
94
immediately after SCI urine is retained, t or f
true - initial indwelling Foley catheter then intermittent
95
skin integrity w/SCI pt.
turn frequently to avoid pressure ulcers - can lead to infection/sepsis
96
temp control w/SCI pt.
no temp control below level of lesion - monitor environment - dress approp.
97
dx studies for SCI
cervical spine x-ray
CAT scan of head if injury to neck
comprehensive neuro exam
98
stabilization of SCI pt. can be
surgical or non-surgical
| focused on stabilization of injured segment
99
when turning a SCI pt do so this way
min 3 people - log roll
100
Which of the following pieces of equipment should be kept at the bedside of a patient immobilized with Crutchfield tongs?
A. Wire cutters.
B. Torque wrench.
C. Pliers.
D. Flat-head screwdriver.
101
SCI immobilization devices
tongs - crutchfield
brace - before and/or after surgery
thoracolumbar orthosis (“body jacket”) *skin care*
102
surgical therapy guidelines for SCI
taken very early - evidence suggests that early cord decompression may result in ↓ secondary injury
103
surgical interventions for SCI include
stabilizing rods
104
if SCI pt. cannot go to surgery right away what intervention is used
kinetic therapy - rotate side-to-side to keep pt. safe
105
return of reflexes in SCI pt. occur
after spinal shock and may be hyperactive
106
autonomic dysreflexia happens in an injury at
t6 or above - sympathetic response - visceral overstimulation
107
s/s of autonomic dysreflexia
hypertensive crises
bradycardia - due to full bladder/bowel irritation
**flushed/sweaty above the lesion
**pale/cool below the lesion
108
if you don't find cause of autonomic dysreflexia and correct it pt can have
hypertensive stroke
| MI
109
autonomic dysreflexia is life threatening, t or f
true
110
most common cause of autonomic dysreflexia
distended bladder/rectum
| Foley catheter kinked?
111
if you cant find cause of autonomic dysreflexia trt symptoms, t or f
true - notify physician - educate family may happen again
112
rehab/home care responsibilities/goals of the nurse
educate what they can expect
| encourage independence
113
grief/depression r/t SCI pt.
let pt. talk - let pt. discuss what they want to discuss
